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Periodontics town

case presentation

Root coverage in the mandibular incisor region is a regular chal-lenge in periodontal plastic surgery for several reasons. First, there is

often a high frenal attachment, shallow vestibule and thin or non-existent quantities of keratinized and attached gingiva 1. This posesproblems during root coverage procedures due to compromisedblood supply as well as excess flap tension which hinders graft sta-bilization. Furthermore, close root proximity and thin interproxi-mal bone may lead to little to no papillary gingiva available for ade-quate flap design and suturing. Finally, anterior crowding oftenresults in labially positioned incisors which may have large facialdehiscences. Due to these anatomical considerations, clinicians areoften limited as far as choosing the proper technique for predictableroot coverage. This article presents a detailed case report as well asother supporting cases demonstrating predictable root coverage uti-lizing a subepithelial connective tissue graft.

Patient Presentation A 26-year-old male presented to the office complaining of “long 

front teeth that are sensitive to cold.” He was concerned about theesthetic appearance of the teeth, and in addition to root coverage,he was planning to pursue orthodontic treatment. Upon clinicalexamination, it was discovered that teeth #s 22-26 exhibited two tofour millimeters of recession, especially on #24 (Fig. 2). In addition,there was both thin and narrow keratinized and attached gingiva present as well as a high frenal attachment. The presence of mildanterior crowding resulted in long, narrow interdental papillae, and#24 being labially positioned.Treatment Options1) A free gingival graft.2) Coronally advanced flap.3) A two-step procedure consisting of a free gingival graft followed

by a coronally advanced flap two months later.4) Guided tissue regeneration utilizing a barrier membrane in com-

bination with a coronally advanced flap.5) Acellular dermal matrix graft.6) Subepithelial connective tissue graft.

 A free gingival graft has been described for increasing the widthof keratinized and attached gingiva,2, 3 but complete root coverage isoften a limitation of this procedure. Furthermore, it often heals witha “tire-patch” appearance that may be unacceptable esthetically(Figs. 1A and 1B).

Periodontal Plastic Surgery Predictable Root Coverage in the Mandibular Incisor Region

David Wong, DDS

Figure 1-B 6 month post-opera- tive view demonstrat- ing root coverage fol- lowing a free gingival 

 graft procedure.

Figure 2-A Pre-operative view showing recession defects on teeth #s 22- 26 along with a high 

 frenum attachment.Note the mild crowd- ing present.

Figure 1-A Pre-operative photo of  teeth #s 24-25 show- ing 3 mm of recession along with a high 

 frenum attachment.

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Figure 2-B A 21 mm by 8 mm connective tissue  graft was harvested from the patient’s right palate.

Figure 2-C The connective tissue graft was sutured to the teeth with 7-0 Vicryl suture material.

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case presentation

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The coronally advanced flap is often considered for obtaining root coverage4. It may be limited by the quantity of keratinized andattached gingiva present. Furthermore, complete root coverage may not be obtained with this technique in the absence of adequate ker-atinized gingiva. Because of the anatomical considerations in thiscase, this technique was eliminated as a treatment option.

The coronal advancement of a previously placed free gingivalgraft has been reported in the literature,5, 6, 7 but was not consideredin this case because of the longer healing time and morbidity asso-ciated with two surgical procedures.

Guided tissue regeneration using both resorbable and non-resorbable barrier membrane has also been shown to be an effectivetechnique for treating recession.8, 9, 10 This technique is most success-

ful when the membrane is fully covered with a coronally advancedflap with no membrane exposure. Once again, this option was elim-inated in this case due to anatomical considerations. Excess flap ten-sion would have to be placed in order to fully cover the membrane,and the risk of membrane exposure could risk an unsuccessful resultthat could possibly be worse than the initial presentation.

The fifth option, an acellular dermal matrix (ADM) graft hasalso been shown to be effective for the treatment of recessiondefects.11, 12, 13 It is a freeze-dried allograft composed of human skinthat has had its cellular contents removed, maintaining essential ele-ments of the tissue structure such as collagen, elastin, and proteo-glycans. Use of ADM is somewhat technique sensitive and requires

a longer healing time. As a result, it was not used in this caseTherefore, a subepithelial connective tissue graft was decided asthe best and most predictable treatment option for this case. Theconnective tissue graft has the advantage of achieving predictableand complete root coverage, while simultaneously gaining kera-tinized and attached gingiva.14, 15, 16, 17 Esthetically, the connective tis-sue graft often heals with an excellent color match to the surround-ing tissues, often leaving no evidence surgery was ever performed.

Surgical ProcedureThere are a variety of techniques and suturing methods for per-

forming the subepithelial connective tissue graft. Only the tech-nique employed for this case will be described.

Local anesthesia was obtained with 2% lidocaine with1:100,000 epinephrine. A 21 mm long by 8 mm wide connectivetissue graft (Fig. 2B) was harvested from the right palate in the areaof the bicuspids and first molar. No epithelium was present on thegraft, and the fatty tissue was trimmed from the graft. The graft wasfurther thinned to 1.5 mm in thickness. The palate was thensutured with 5-0 Vicryl suture. An acrylic stent was then placedover the donor site to aid in hemostasis as well as to provide protec-tion during the healing phase of treatment.

The recipient site extended from cuspid to cuspid, and was pre-pared in the following manner: Intrasulcular incisions were made

 with a #15 blade on the facial surfaces of #s 22-27. A full thicknessmucoperiosteal flap was elevated on the facial surfaces of the teethto the mucogingival junction. From the mucogingival junction, theflap was sharply dissected with a #15 blade, creating a split-thick-ness flap. Care was taken not to excessively thin the flap and com-promise the blood supply. It was also important in this techniquethat the papillae were left intact and not incised. After checking theflap for mobility and passivity, the roots were then scaled with asonic scaler and hand instruments. No effort was made to removethe convexity of the roots. No root conditioning was performed.

Following the preparation of the recipient site, the connectivetissue graft was then placed over the roots and checked for appro-priate length and width. It was imperative the graft cover not onlythe roots but also extend an additional 3 mm beyond the dehis-cences onto the surrounding alveolar bone. After being assured ofthe proper dimensions, the connective tissue graft was sutured tothe incisors at the cementoenamel junctions with interrupted slingsutures using 7-0 Vicryl suture (Fig. 2C). The mucoperiosteal flap

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 was then thinned with Legrange scissors in the papillary areas toallow for proper thickness of the interdental papillae. The flap wasthen coronally advanced and sutured to the teeth also utilizing interrupted sling sutures using 7-0 Vicryl sutures (Fig. 2D). Noattempt was made to completely cover the connective tissue graft

 with the flap. The lower lip was then manipulated laterally and ver-

tically to ensure no excess tension was placed on the flap or graft.This was important because any movement of the graft during thismanipulation would lower the opportunity for complete root cov-erage to be achieved. Since the graft remained stationary during thislateral and vertical lip movement, the surgery was complete. Positivepressure was placed on the recipient site for 5 minutes prior to dis-missing the patient.

Post-operative instructions included placing the patient on a soft diet and instructing him to avoid contact or trauma to the area as well as avoiding pulling the lower lip in any direction. Thepatient was placed on analgesics for post-operative pain manage-ment and 0.12% chlorhexidene rinses twice a day for two weeks.No other oral hygiene practices were allowed in the recipient site.

No other medications were prescribed.The patient was seen at one week for suture removal. Healing 

 was unremarkable, and the patient complained only of mild painand discomfort. The patient was further seen at three, six, nine, andtwelve weeks post-operatively to check for proper plaque removaland healing. The area was not probed until six months post-opera-tively which revealed one and two millimeter sulcus depths, suggest-

ing the presence of new attachment (Fig. 2E). At six months, 100%root coverage was achieved. Minimal inflammation was presentdespite less than optimal oral hygiene. Furthermore, an adequate

 width and thickness of keratinized and attached gingiva was present(Fig. 2D).Discussion

The predictability and amount of root coverage that can beobtained for teeth with any amount of recession depends on theclassification of recession. The classification system utilized wasdescribed by Miller and will be reviewed briefly.18 Class I recessionincludes marginal tissue recession that does not extend to themucogingival junction. There is no loss of bone or soft tissue in theinterdental area. This type of recession can be narrow or wide. ClassII consists of marginal tissue recession that extends to or beyond themucogingival junction. There is no loss of bone or soft tissue in theinterdental area. Class III consists of recession that extends to orbeyond the mucogingival junction, but there is bone and/or soft tis-sue loss interdentally or malpositioning of the tooth. Class IV ismarginal tissue recession that extends to or beyond the mucogingi-

val junction in the presence of severe bone loss and soft tissue lossinterdentally and/or severe tooth malposition. For Class I and ClassII recession, up to 100% root coverage can be anticipated with thesubepithelial connective tissue graft (Figs. 2A-2E, 3A-3B, and 4A-4B). In the above figures, complete root coverage was expected andachieved due to the adequate interdental papillae height and lack ofinterdental bone loss.

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Figure 3-A Pre-operative view of reces- sion on teeth #s 23-25 with a high frenum attachment.

Figure 2-DThe flap was coronally posi- tioned over the majority of the connective tissue graft and sutured with 7-0 Vicryl suture.

Figure 2-EResults at 8 months demon- strating complete root coverage of #s 22-26.

Figure 3-BResults at 6 months show- ing complete root coverage.

Figure 4-APre-operative view of reces- sion on teeth #s 23-26.

Figure 4-B Results at 6 months show- ing complete root coverage.

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ConclusionsObtaining predictable root coverage in the lower incisor region

offers many challenges for the clinician. The presence of crowding,a midline frenum, thin keratinized and attached gingiva, a shallow vestibule, and narrow interdental papillae makes sound surgicalplanning and technique critical. Compromises in blood supply,

excess flap tension, among other considerations must be addressedbecause failure in the lower incisor region can result in a situationthat is often worse than the initial presentation. A subepithelial con-nective tissue graft has been employed in such situations for pre-dictable and esthetically acceptable root coverage. Success in thesecases has been attributed to atraumatic surgical technique, a conser-vative flap design that includes the narrow interdental papillae,proper graft size, precise suturing with 7-0 sutures, as well as theabsence of flap tension from the midline frenum.

Bibliography 1. Woofter C. The prevalence and etiology of gingival recession.

Periodont Abstr 1969; 17: 45.2. Miller PD Jr. Root coverage using a free soft tissue autograft fol-

lowing citric acid application. Part I. Technique. Int J PeriodontRestor Dent 1982; 2: 65.

3. Miller PD Jr. Root coverage using a free soft tissue autograft fol-lowing citric acid application. Part III. A successful and pre-dictable procedure in areas of deep wide recession. Int JPeriodont Restor Dent 1985; 5: 15.

4. Bernimoulin JP, Loscher B, Muhlemann HR. Coronally reposi-tioned periodontal flap. J Clin Periodontol 1975; 2: 1.

5. Caffesse RG, Guinard E. Treatment of localized gingival reces-sions. Part II. Coronally repositioned flap with a free gingivalgraft. J Periodontol 1978; 49: 358.

6. Matter J. Free gingival graft and coronally repositioned flap. A 2-year follow-up report. J Clin Periodontol 1979; 6: 437.

7. Maynard, JB. Coronal positioning of a previously placed autoge-nous gingival graft. J Periodontol 1977; 48: 151.

8. Cortellini P, Clauser C, Pini-Prato GP. Histologic assessment of new attachment following the treatment of a human buccalrecession by means of a guided tissue regeneration procedure. JPeriodontol 1993; 64: 387.

9. Harris RJ. A comparison of 2 root coverage techniques: Guidedtissue regeneration with a bioabsorbable matrix style membrane

versus a connective tissue graft combined with a coronally posi-tioned pedicle graft without vertical incisions. Results of a seriesof consecutive cases. J Periodontol 1998; 69: 1426-1434.

10. Pini-Prato G, Tinti C, Vincenzi G, et al. Guided tissue regener-ation versus mucogingival surgery in the treatment of humanbuccal gingival recession. J Periodontol 1992; 63: 919.

11. Aichelmann-Reidy ME, Yukna RA, Evan GH, Nasr HF, MayerET. Clinical evaluation of acellular allograft dermis for the treat-ment of human gingival recession.

12. Harris RJ. A comparative study of root coverage obtained withan acellular dermal matrix versus a connective tissue graft:Results of 107 recession defects in 50 consecutively treatedpatients. Int J Periodontics Restorative Dent 2000; 20: 51-60.

13. Henderson, RD, Drisko CH, Greenwell H. Root coverageusing Alloderm acellular dermal graft material. J ContempDent Pract 1999 Oct; (1)1: 024-030.

14. Allen AL. Use of the supraperiosteal envelope in soft tissuegrafting for root coverage. II. Clinical results. Int J PeriodonticsRestorative Dent 1994; 14: 303-315

15. Bouchard P, Etienne D, Ouhayoun JP, Nilveus R. Subepithelialconnective tissue grafts in the treatment of gingival recessions.

 A comparative study of 2 procedures. J Periodontol 1994; 65:929-936.

16. Langer B, Langer L. Subepithelial connective tissue graft tech-nique for root coverage. J Periodontol 1985; 56: 715.

17. Wennstrom JL. Mucogingival therapy. Ann Periodontol 1996;1: 671-701.

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Periodont Restor Dent 1982; 2: 65.

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Dr. Wong maintains a solo practice in  periodontics in Tulsa, Oklahoma. He is a  graduate of the University of Oklahoma and received his periodontal training at the University of Missouri-Kansas City. The 

 primary focus of his practice are in the areas of periodontal plastic surgery and dental implants. He can be reached at david@tulsagums.com.